Đang chuẩn bị liên kết để tải về tài liệu:
2017 Geriatric Trauma & Critical Care 2

Acute Vascular Insufficiency.in the Elderly20Michael J. Sise.Educational Objectives.IntroductionThe evolving demographic shift in the United States.resulting in increasing numbers of elderly citizens directly.impacts all of healthcare. Emergency services now are.inundated with geriatric patients who often present with.surgical problems complicated by multiple comorbiditiesThe key to the successful management of surgical emergencies in the elderly is not only early diagnosis and.prompt treatment but also aggressive management of multiple pre-existing major health problems. This is especially true in acute ischemia in the elderly. Delay in.diagnosis is common in these patients despite the fact that.a simple history and physical examination often are sufficient to make the diagnosis. These delays lead to high.morbidity and mortality because the elderly frequently.have multiple serious comorbidities and limited reserve to.tolerate the sequelae of ischemia. The goal of this chapter.is to provide a useful approach to the management of.acute vascular insufficiency in the elderly for the acute.care general surgeon. This review includes extremity and.abdominal acute arterial and venous occlusive diseases.and presents algorithms and checklists to help organize.and direct diagnosis and management. Illustrative case.presentations of each major etiology of acute vascular.insufficiency conclude this chapter and provide an integration of the key elements of successful early diagnosis.and prompt treatment.The incidence of peripheral arterial disease (PAD), c­ oronary.artery disease (CAD), and cardiac arrhythmias among the.elderly is extremely high and increasing yearly [1–4]Combined with the steadily rising life expectancy, the.problems of acute limb ischemia and acute mesenteric ischemia are of growing importance to acute care surgeonsMore than 25 % of the elderly have clinically significant.and active health problems related to PAD, CAD, or atrial.fibrillation [3, 5]. Acute vascular insufficiency presents in a.variety of settings. Although the emergency department.remains the most common location to encounter these.patients, the ICU, medical-surgical floors, and the operating room may also be the site of consultation for these.emergencies. However, the work-up remains straightforward and is based upon a thorough history, an appropriate.examination, adjunctive Doppler pressure measurements or.CT imaging studies, and, in a few compelling clinical settings, an immediate operation. The time urgency of diagnosis and effective treatment is based upon the “golden.period” of 6–8 h within which adequate blood flow must be.restored if limb-threatening tissue loss or life-threatening.bowel necrosis is to be prevented. Acute limb ischemia is.much more common than acute mesenteric ischemia but.shares a number of characteristics including etiology,.pathophysiology, and the need for immediate diagnosis and.treatment [6, 7]Acute Limb IschemiaM.J. Sise, MD, FACS.Department of Surgery, UCSD School of Medicine, Scripps Mercy.Hospital, 4077 5th Avenue MER-62, San Diego, CA 92103, USA.e-mail: sise.mike@scrippshealth.org; mjsise@gmail.comAcute, nontraumatic limb ischemia is usually due to either.cardiac source emboli or thrombotic occlusion of pre-­.existing occlusive arterial disease. Although less common,.iatrogenic arterial occlusion is a growing problem for the.acute care surgeon [9]. Most, if not all of these patients, have© Springer International Publishing AG 2017.F.A. Luchette, J.A. Yelon (eds.), Geriatric Trauma and Critical Care, DOI 10.1007/978-3-319-48687-1_20201.202major comorbidities that complicate their management [10]Prompt diagnosis and treatment are essential to successful.managementPathophysiology.Extremity ischemia is the result of either acute arterial occlusion or acute worsening of chronic occlusive diseaseInfrequently, severe acute venous occlusion results in.­ischemia secondary to arterial vasoc